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General NPI Number Information
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NPI Number | 1619583036
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Entity Type | Organization
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Legal Business Name | SHERRY BROADWELL PHD LLC
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Dates
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Enumeration Date | 09/21/2020
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Last Update Date | 09/21/2020
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Provider Practice Location Address
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Address Line | 517B GREEN STREET
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City | GAINESVILLE
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State | GA
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Zip | 30501
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Country | US
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Telephone | 706-949-3131
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 716
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City | CLARKESVILLE
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State | GA
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Zip | 30523-0012
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Country | US
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Telephone | 706-949-3131
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | LYNETTE CLARK
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Credential |
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Telephone | 770-339-7667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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